Aseptic loosening of the acetabular component in relation to the positioning of prosthesis

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Shishir Rastogi, V Trikha, S Bhan, C Bal

Forty-eight patients having 64 cemented or cementless total hip arthroplasties were followed up. The follow up period ranged from 18 to 120 months (mean 37 months). The overall clinical outcome was better in cementless than in cemented prostheses. Aseptic loosening was confirmed using 3 phase bone scan in hips having clinical pain or signs of loosening in the radiographs. Two patients had confirmed aseptic loosening of the acetabular component, out of which one had undergone revision for clinical symptoms. Both these patients had cemented acetabular cups. The initial positioning of the acetabular cup was 48.30 (average) with 64% placed in neutral position while 25% were in vertical position. Out of the two aseptically loose components, one each was in horizontal and vertical position.

Post-operative deep vein thrombosis (DVT) is a major preventable complication in orthopaedic patients undergoing major joint surgeries. Early, easy and accurate detection of deep vein thrombosis (DVT) in such patients can prevent fatal pulmonary embolism (PE) and post-thrombotic syndrome. The purpose of this study was to compare the sensitivity and specificity of colour doppler duplex sonography (CDDS) to contrast venography (CV) which is considered as the gold standard. A total of 44 patients were included in the study, 24 patients developed deep vein thrombosis (DVT) despite thromboprophylaxis. The sensitivity and specificity of colour doppler duplex sonography (CDDS) was 91.66% and 100% respectively for deep vein thrombosis (DVT). Colour doppler duplex sonography (CDDS) appears a viable and reliable option for routine screening of patients for deep vein thrombosis (DVT).

Incidence of deep vein thrombosis in patients with fractures around hip joint : a prospective study

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H Sharma, L Maini, N Agrawal, A Upadhyay, J Vishwanath, BK Dhaon

Post-operative deep vein thrombosis is believed to be rare in Asians. In this prospective study we investigated 112 consecutive patients, aged more than 40 years, who underwent surgery for fractures around hip joint. The color doppler ultrasound was used to detect thrombosis in proximal thigh veins. None of the patients received prophylaxis against DVT. We found a significant incidence of 19.6%, which makes a strong case for routine prophylaxis in all patients with risk factors undergoing hip fracture surgery.

Twenty focal dome osteotomies were carried out on 11 patients with moderate to severe genu valgum where spontaneous correction was unlikely and epiphyseal stapling would have been unpredictable. The average age at operation was 13.01 years. The average preoperative intermalleolar distance, femorotibial angle and mean lateral distal femoral angle were 17.5cms,19.25 0 - and 74.85 0 respectively which were corrected postoperatively to average 2.25cms, 7.75 0 and 86.9 0 respectively. All patients were pleased with cosmetic correction. We conclude that focal dome osteotomy, being closest to the apex of the deformity i.e. the knee, is a biomechanically sound osteotomy, which leads to complete axial realignment and excellent apposition of osteotomy fragments without translation and limb length alteration after the desired correction is achieved.

Sixty patients suffering from primary osteoarthritis of the knee were selected for treatment with intraarticular Sodium Hyaluronate regimen of three injections at weekly intervals. One year follow up of these patients revealed a satisfactory reduction of pain on a Visual Analogue Score (VAS) on an average of 8 to 3. Range of movement also improved significantly to improve activities of daily living. Four of the patients had pre-injection arthroscopies and two so far have had post-injection arthroscopies. It has been found that there was some evidence of chondroprotection. This treatment modality has the potential to become an important option in our armamentarium for osteoarthritis given that lesser operative procedures (arthroscopy, HTO) do not achieve long symptom free intervals.

Complex open injuries of the extremities resulting from a proliferation of motor vehicle and progressive urban violence are seen with increasing frequency. With advanced transport, communication system, better antibiotic agents, multidisciplinary team approach, microvascular flaps, etc many western countries have been able to salvage the limbs which were considered hopeless in the past. This is in contrast with the reality in our country because of lacunae in several fields, which begins with poor transport communication system, lack of triage and referral strategies from a peripheral hospital to a tertiary referral trauma center. On the other hand health economics is emerging as a great player in making decisions regarding new treatment strategies. Blind or subjective decision to go head with salvage or amputation is not advisable. Failed efforts at limb salvage also are associated with increased patient mortality, morbidity and high hospital cost. [1] In this context, we report a study evaluating the predictability of limb salvage based on MESS score and the ultimate outcome as regards limb salvage.

The mangled extremity severity score (MESS) based on four significant criteria (with increasing points with worsening prognosis) i.e. skeletal injury, limb ischaemia, shock and patient age, has become a standard method to determine which one of the mangled extremities will eventually undergo amputation or salvage. Keeping in view paucity of study on Indian patients, a prospective trial of MESS was done in 50 patients having 56 mangled extremities during last 3 years. A significant difference between MESS value of salvaged limbs (4.7) and amputated limbs (8.6) was found. MESS score of more than 7 was most specific and was found to have a positive predictive value of 100 percent. The results have been compared with Western literature and authors suggest that nerve injuries and irreparable soft tissue loss should be given an extra point each. In bilateral cases, MESS score of each limb should be properly assessed (especially when patient is in shock), as the score may increase because of the other injured limb.

Sauve Kapandji technique for the treatment of complications of distal radial fractures

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SC Gaur, DC Srivastava

Nineteen cases of distal radial fractures with severe wrist pain especially on ulnar side and decreased rotation of forearm due to derangement of distal radio-ulnar joint, were treated by Sauve Kapandji technique between 1985 to 1999. The mean age was 31 years (range 23 to 78 years) and the mean follow up period was 34 months. Only intraperiosteal resection of ulna with fusion of distal radio-ulnar joint was done. In two cases radio-carpal joint were also fused because of severe derangement of distal radial articular surface and in one case the corrective distal radial osteotomy was done. The pre-and postoperative assessment of cases was done on the basis of Mayo modified wrist score. Wrist pain, rotation of forearm, grip strength, ulnar variance and other complication were taken into account. There was significant improvement in pain in 16 cases and moderately in three cases. Rotation of forearm improved to within 6 degree of contralateral side. All cases showed significant improvement in ulnar variance. None showed any alarming complication. Functional improvement was excellent in 10, good in 6 and fair in 3 cases.

Results of a prospective analysis of 14 patients, who were assessed at a mean of 3 years after treatment for an acute episode of reflex sympathetic dystrophy (RSD) of the hand following Colles' fracture, are presented. The mean UAS pain score was SD 4.8. Only two (14.2%) patients were completely free of pain, six (42.8%) had uniformly restricted and painful movements of wrist and hand, 10 (71.4%) had marked weakness of grip and four (28.5%) had slightly reduced grip strength. The mean RSD score on affected side was found to be significantly high in 6 patients who were either diabetic or chronic alcoholics. The mean interval between removal of cast and reflex sympathetic dystrophy diagnosis was 1.5 months. The main outcome measures were the impairment of hand function and loss of full fist muscle strength (71.4%). Pain was quantified with a visual analogue scale in 85.7%. Two patients changed their original occupation; four stopped their work for more than one year. The result showed a high coincidence between reflex sympathetic dystrophy and associated, psychological background in 57.1%, it was also noticed that an early diagnosis and treatment did not help to lessen the impairment and disability.

Correlation between MRI and intra-operative findings in prolapse intervertebral disc

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SK Lunawat, DK Taneja, A Malviya

Prolapsed intervertebral disc is an important and common cause of low backache. MRI has now become universally accepted investigation for prolapsed intervertebral disc. We, however, regularly come across situations, when MRI shows diffuse disc bulges, even at multiple levels, which cannot be correlated clinically and when such cases are operated, no significant disc prolapse is found resulting in negative exploration. Obviously MRI has over diagnosed the condition. The aim of the present study is to establish diagnostic accuracy of a costly investigation like MRI in significant prolapsed disc corroborated by clinical and intra-operative findings. Seventy symptomatic MRI confirmed prolapsed intervertebral disc patients were operated, of which only 55 required excision of disc. In other 15 cases of segmental canal stenosis, wide laminectomy was enough. No instrumentation or stabilization was done as all had surgically limited exposure. It was concluded that MRI is highly sensitive investigation in prolapsed intervertebral disc but clinical correlation is a must to determine level and extent of surgery. The surgical correlation with MRI findings of 'significant disc prolapse' causing compression was more in single level and, lateral disc prolapse in comparison to multiple, central and paramedian disc prolapse.

Cell viability in meniscal allografts after preservation in low concentrations of formalin

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MS Dhillon, M Khullar, S Apsinghi, ON Nagi

In meniscal allograft transplantation, cell viability is an important feature for success. Since formalin preservation of orthopaedic allografts is a common procedure in our country, we attempted to analyze the viability of cells in meniscal tissue after preservation in different concentrations of formalin. Twenty-four rabbit meniscal samples were assessed (8 samples each preserved in 0.25%, 1% and 5% of formalin solution for 3 weeks) to see which concentration was best suited for cell viability. For assessing viability of meniscal fibro-chondrocytes, the uptake of radioactive Na235SO4 and LDH activity in these cells was taken as indirect evidence of metabolic activity. Fresh meniscal samples were taken as controls. Menisci preserved in 0.25% of formalin showed similar uptake of radioactive Na235SO4 and LDH activity as the controls, reflecting similarity in the levels of cell viability, as well as, indicating ongoing metabolism. The menisci preserved in 1% and 5% concentrations of formalin had decreased radioisotope uptake. Thus menisci preserved in 0.25% formalin are more viable and metabolically active as compared to those preserved in higher concentrations. This concentration of formalin, however, may not be sufficient to act as a preservative, nor may it be enough to cause sterility, raising questions about the optimal concentration of formalin to be used for allograft preservation.

Prevention of growth abnormalities in epiphyseal injuries An experimental study

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SC Goel, V Kapoor

The epiphyseal injuries may result in growth arrest of the damaged physes and resultant deformity or limb length discrepancy. In this experimental study free muscle grafts were used to fill up the surgically created defects in epiphyseal plate of rabbit femora. The objective was to find a suitable alternative to free fat grafts, which are in use in a variety of clinical situations arising from the bone bridge formation across an injured epiphyseal plate. Drill hole defects were created in the distal epiphyseal plate of right femora and filled with free muscle taken from adjacent vastus lateralis in 24, four week old Belgian rabbits and compared with controls. Free muscle interposed into the physeal defect prevented bone bridge formation across the injured physes. Furthermore free muscle was found to be a much stable tissue with little chances of migration from the grafted site thus ensuring the consistency of the results expected.

Survey of 540 orthopaedic surgeons was conducted with the help of a questionnaire to find out the current status and the management pattern of osteoarthritis in Indian context. The results have shown changing trends in epidemiology and lack of a standard approach in management. The areas which need to be strengthened are role of physiotherapy, medical management of pain, patient education and trained surgeons to perform modern surgical treatments. There is an urgent need to mobilize public opinion for increased allocation of resources to cope up with increasing number of people with osteoarthritis as the percentage of elderly in our population rises.